1. Diagnostic Imaging Approach to a Supratentorial SOL in an Adult
Antoinette Reinders
Dept of Diagnostic and Interventional Radiology
University of the Free State
Aug 2012

2. Approach Age Location Tumour spread Characteristics on CT and MRI
Intra vs extra axial
Anatomical compartment
Midline crossing
Tumour spread
Characteristics on CT and MRI
Spectroscopy
Calcification/edema/mass effect
Enhancement
Differential diagnoses
“Tumor mimickers”

3. Brain Tumours
Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

4. Major Anatomical considerations
Intra axial
Hemispheres (cerebrum/cerebellum)
Brainstem
Sellar/supraseller
Pineal
Ventricular
Extra axial
Dural based
Bone tumours
Nasopharyngeal tumours

5. Approach Location Intra-axial vs Extra-axial
Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

6. Extra axial tumour
Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

7. Intra vs Extra axial
Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

8. Approach Location Grey matter White matter Grey/white matter interface
Cortical/subcortical
White matter
Grey/white matter interface
Dural surface
Abut the meninges
Ventricles
Foramen of Monroe
Trigonum of the lateral ventricles
Pineal gland
Sella/suprasellar

9. Robert Wood Johnson University Hospital. Available from URL:

11. Approach Cross midline Multifocal disease
Glioblastoma Multiforme, Radiation necrosis, Meningioma, Lymphoma, Epidermoid cyst, MS
Multifocal disease
Phacomatoses
NF1: Optic gliomas, astrocytomas
NF2: Meningiomas, Ependymomas, Schwannomas, Choroid plexus papillomas
TS: Subependymal tubers, Giant cell astrocytomas
VHL: Hemangioblastomas

13. Approach Tumour spread Subarachnoid seeding WM Tracts Foramina PNET
Ependymoma
GBM
Lymphoma
Oligodendroglioma
WM Tracts
Astrocytoma
Pilocytic, Fibrillary, Gemistocytic, Protoplasmic
Foramina

14. Tumour Spread
Pleomorphic xantoastrocytoma
Ependymoma of 4th ventricle

15. Approach Characteristics MRI CT Edema Cystic Mass effect
Fat containing
Spectroscopy CT
Calcifications
Haemorrhage
Homogenous or heterogenous appearance
Periosteal reaction

16. Characteristics on CT

17. Haemorrhage Common haemorrhage Not common haemorrhage
Glioblastoma multiforme
Germ cell tumours
Metastases
Choroid
Thyroid
Bronchus
Mamma/melanoma
Renal
Medulloblastoma
Craniopharyngioma
Colloid cysts/central neurocytoma
Oligodendrogliomas
Ependymal
Giant cell astrocytomas
Chordoma
Epidermoid/dermoid

18. Characteristics on MRI

19. Characteristics on MRI

20. Diffusion Weighted Imaging
Abscesses, infarcts have ABNORMAL diffusion – restriction
Tumours have NORMAL diffusion – no restriction

21. Approach Enhancement Destruction of BBB in order to enhance
Homogenous vs heterogenous enhancement
Enhancement of gliomas = higher grade of malignancy
NB in follow up
Diffusion weighted
Restricted diffusion in abscesses and not in tumours
Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:

22. Approach No Enhancement Patchy Enhancement Homogenous Enhancement
Low grade astrocytomas
Metastases
Cystic non tumour lesions
Oligodendroglioma
Lymphoma
Dermoid
GBM
Germinoma and pineal tumours
Epidermoid
Radiation necrosis
Pituatary macroadenoma
Arachnoid cyst
Pilocytic astrocytoma
Hemangioblastoma
Gangliocytoma
Meningioma
Schwannoma

23. Common things.....
Astrocytoma
Oligodendroglioma

24. Approach Differential diagnoses
Dural based – Meningioma, Dural metastases, Sarcoid, Haemangiopericytomas, pineoblastoma, lymphoma
Cortical based – Dural AV malformation, Herpes encephalitis
Multifocal disease – Septic emboli, Abscesses and Multiple Sclerosis
Sellar - Aneurysm

25. Take home points... Age of patient Location Tumour spread
Intra vs extra axial
Crossing midline
Multifocal disease
Tumour spread
Characteristics on CT/MRI
Calcifications
Haemorrhage
Spectroscopy
Enhancement pattern
Differential diagnoses

26. Cellphones?
“Although our results overall do not indicate an increased risk of glioma in relation to mobile phone use, the possible risk in the most heavily exposed part of the brain with long-term use needs to be explored further before firm conclusions can be drawn.”
Int J Cancer Apr 15;120(8):
Mobile phone use and risk of glioma in 5 North European countries.
Raised risks of glioma with mobile phone use, as reported by one (Swedish) study forming the basis of the IARC's re-evaluation of mobile phone exposure, are not consistent with observed incidence trends in US population data, although the US data could be consistent with the modest excess risks in the Interphone study.
BMJ Mar 8;344:e1147. doi: /bmj.e1147.
Mobile phone use and glioma risk: comparison of epidemiological study results with incidence trends in the United States.
BMJ May 1;344:e3083; author reply e3088. doi: /bmj.e3083.
Association of mobile phone use with adult brain cancer remains plausible
Davis DL, Miller AB, Philips A

27. Bibliography
Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL:
Koeller KK, Sandberg GD. Cerebral intraventricular Neoplasms: Radiologic-Pathologic correlation. RadioGraphics 2002; 22:
Hoon Shin J, Kyu Lee H, Khang SK et al. Neuronal tumors of the central nervous system: radiologic findings and pathologic correlation. RadioGraphics 2002; 22:
Robert Wood Johnson University Hospital. Available from URL:
Dahnert W. Radiology Review Manual 6th ed. Lippincott Williams & Wilkins 2007
Weissleder et al. Primer of Diagnostic Imaging 4th ed. Mosby Elsevier 2007